Provider Demographics
NPI:1194703546
Name:FLANDERS, MARY KATHLEEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHLEEN
Last Name:FLANDERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MAGAZINE ST
Mailing Address - Street 2:#5
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3942
Mailing Address - Country:US
Mailing Address - Phone:617-821-6870
Mailing Address - Fax:617-975-0989
Practice Address - Street 1:1235 VIKING TOPAZ CT
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-7622
Practice Address - Country:US
Practice Address - Phone:617-821-6870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
MAAP2121363AS0400X
VA0110002066363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010203155Medicaid
VATN0139OtherJOHN DEERE